Provider Demographics
NPI:1508634510
Name:WILLIAMS, KYLIE NICOLE (MSOT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:NICOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 PARISH BROOK CT
Mailing Address - Street 2:
Mailing Address - City:KAWKAWLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48631-9799
Mailing Address - Country:US
Mailing Address - Phone:989-316-6186
Mailing Address - Fax:
Practice Address - Street 1:1455 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1151
Practice Address - Country:US
Practice Address - Phone:810-664-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013745225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist